Synopsis On the afternoon of 06 August 1994, the Canadian general cargo vessel CATHERINE DESGAGNS was in Lorain Harbor, Ohio, United States, proceeding outbound in ballast. In attempting to stop for a highway bridge which was not yet fully opened, the CATHERINE DESGAGNS went out of the channel and through a marina complex, sinking and damaging pleasure craft and floating docks before coming to a stop against the embankment on the eastern approach to the bridge. Further damage was caused to pleasure craft when the CATHERINE DESGAGNS went astern, preparatory to passing through the opened bridge. The Board determined that the CATHERINE DESGAGNS was unable to stop on her approach to a highway bridge in Lorain Harbor because her speed was excessive and greater than the permitted speed limit. The fact that resources available to facilitate the navigation of the vessel were not utilized contributed to the occurrence. 1.0 Factual Information 1.1 Particulars of the Vessel 1.2 Description of the Vessel 1.2.1 General Arrangement The CATHERINE DESGAGNS is a four-hold general cargo vessel with the machinery space, accommodation, and navigation bridge located aft. 1.2.2 Manoeuvring Characteristics Orders with respect to manoeuvring the main engine are relayed from the wheel-house to the engine-room by means of a telegraph. The engineer on duty acknowledges and executes the orders as required. The transverse thrust created by a right-handed propeller tends to swing a vessel's head to starboard when the propeller is turning astern and to port when the propeller is turning ahead. The effect of the transverse thrust is at its maximum when the vessel has little way on and decreases as the vessel's speed increases. 1.3 History of the Voyage On 06 August 1994, the CATHERINE DESGAGNS was alongside the Jonnick dock in Lorain. At about 1210[3], she completed discharging a cargo of steel ingots. At about 1228, the vessel left the berth and, because of the limited width of the river off the dock, proceeded upstream to the lower turning basin to swing to head out to Lake Erie. While attempting to swing, the CATHERINE DESGAGNS became temporarily embedded in the soft river bed; because of this and the reported moderate northerly breeze, the vessel could not be swung to head down river until about 1430, after much manoeuvring. At about 1435, in the vicinity of the Jonnick dock, the CATHERINE DESGAGNS sounded one long and one short blast to request the opening of the Norfolk and Western railway bridge. The vessel passed through the bridge at about 1437 while the span was still being raised and the marine traffic signal was still set at red. At about 1439, when she was about to negotiate the last bend on the approach to the Charles Berry highway bridge, the vessel sounded one long and one short blast to request the opening of that bridge. The bridge operator acknowledged the signal but, about half a minute later, sounded five short blasts to indicate that the bridge could not be opened in time. The CATHERINE DESGAGNS attempted to stop by going full astern and dropping the port anchor but she sheered to starboard out of the channel and through a marina complex before she came to a stop with the forepart of the vessel against the embankment which comprises the eastern approach to the bridge. The time was approximately 1442. Floating docks and pleasure craft were damaged and sunk as the CATHERINE DESGAGNS ran into the marina. Further damage was inflicted when the bridge was open and the vessel backed up and turned, preparatory to making her passage through the bridge. The vessel did not follow directions from the U.S. Coast Guard (USCG) to remain in position in the marina but, after clearing the bridge, the CATHERINE DESGAGNS was secured at a berth at the river mouth on the instructions of the USCG. 1.4 Injuries to Persons Many people hastily evacuated pleasure craft to seek safety on the river bank when the CATHERINE DESGAGNS was seen to be coming into the marina, but no injury was reported. 1.5 Damage 1.5.1 Damage to the Vessel There was no apparent structural damage to the CATHERINE DESGAGNS. 1.5.2 Other Damage Marina dock facilities were damaged, 12 pleasure craft were sunk, and 33 other pleasure craft were damaged to varying degrees when struck by the vessel and/or her propeller during the occurrence. 1.6 Environmental Damage Several hundred litres of gasoline were released by a number of the pleasure craft sunk or damaged in the occurrence. The resulting gasoline fumes caused the bridge to be closed to road traffic for four and a half hours. Booms were deployed to facilitate the containment and recovery of the leaked gasoline. 1.7 Vessel Certification The CATHERINE DESGAGNS was manned, certificated, and equipped in accordance with the appropriate regulations. 1.8 Personnel Qualifications and Experience The master's career in the marine industry began in 1939. He was the holder of a Master Mariner's Certificate of Competency issued in Canada in 1954. He was qualified as a Great Lakes pilot and had been employed as an unrestricted pilot in International District No. 2 from 1964 to 1987, during which time he had made several calls at Lorain Harbor. After his retirement in 1987, he had been engaged by the owners of the CATHERINE DESGAGNS as master on a casual basis since 1988, and vessels he commanded and which were under his conduct had been granted pilotage exemptions for all districts under the Great Lakes Pilotage Authority. He had called at Lorain three times while employed with the owners of the CATHERINE DESGAGNS. The chief officer had been going to sea since 1967 and held a Master Mariner's Certificate of Competency issued in Canada in 1987. She had been in the owners' employ since 1987, during which time she had served on occasion as master, but mainly as chief officer. This was her first trip to Lorain. The quartermaster's seafaring career began in 1973. He had served mainly on the Great Lakes, with over 16 years' experience as quartermaster. 1.9 Bridge Watch For the vessel's outward passage down the Black River, the master and the chief officer were on the bridge, with the quartermaster at the helm, and the second officer and the bosun were posted forward, on the forecastle. The master had the conduct of the vessel, and the chief officer's duties were not specific. However, the chief officer was occupied with monitoring the quartermaster and estimating the vessel's distance from shore as the passage proceeded. The chief officer also recorded the vessel's progress by noting the time of passing certain points along the river. The chief officer did not use the recorded times to monitor the vessel's speed. The master did not discuss the vessel's departure from Lorain with any of the officers, and there was no passage planning, which would have included identifying potential hazards, speed limits, and signalling requirements before the CATHERINE DESGAGNS sailed. No (vessel) bridge resource management was carried out to ensure effective use of crew, equipment, and procedures during the down-river passage. The master had received no training in bridge resource management and was not familiar with the concept. 1.10 Communications The CATHERINE DESGAGNS made Security calls on very high frequency (VHF) radiotelephone channel 16 one hour and half an hour before departing from Jonnick dock. Communication with the bridge operators was by means of sound signals. There was no VHF radio communication between the vessel and the bridge operators. At about 1000, the railway bridge operator was advised by the vessel's agent that the CATHERINE DESGAGNS would be leaving Jonnick dock at about 1400. On receiving this information, the operator checked with the dispatcher and established that no trains were scheduled for the bridge. He advised the dispatcher that he would be opening the bridge for an outbound vessel and prepared the bridge for opening, leaving the centre span closed but ready to be raised at the vessel's signal. The United States Coast Pilot for the Great Lakes, Volume 6, states, in part: When a vessel must pass two or more drawbridges close together, the opening signal is given for the first bridge. After acknowledgement from the first bridge ... the opening signal is given for the second bridge, and so on until all bridges ... have acknowledged that they will open promptly[4]. About two minutes after passing the railway bridge and about three cables from it, the CATHERINE DESGAGNS gave the signal requesting the opening of the highway bridge. At this time, she was only about two cables from the highway bridge. The signal to request that a bridge be opened is one long blast and one short blast. If the bridge can be opened, the operator acknowledges with the same signal. Five short blasts are used to signal a vessel that the bridge cannot be opened or, if open, must be closed promptly. 1.11 Lorain Harbor Bridges Lorain Harbor includes the lower 2.6 miles of the Black River. Three bridges cross this stretch of the river. The fixed-span 21st Street highway bridge is furthest upstream and is above the lower turning basin. The next bridge downstream is the Norfolk and Western railway lift bridge. The time required for the operator to prepare to open this bridge is one minute, and one and a half minutes are required to raise the span. A total of two and a half minutes is required before the vessel traffic signal changes from red to green to indicate that a vessel may proceed. The outer bridge is the Erie Avenue or Charles Berry highway bridge, a bascule bridge. When the operator acknowledges the request to open the bridge, he first has to stop the road traffic. A signal is sounded for 25 seconds before gates are lowered. The operator then has to check that there are no pedestrians. This takes about a minute and between 2 1/2 and 3 minutes are then required to raise the drawspans. A total of between 3 1/2 and 4 minutes is required before the green light for a vessel to proceed is given. 1.12 Speed Limit in the River The speed limit in Lorain Harbor is 5.2 knots (6 statute miles per hour). The distance from the lower turning basin to the Charles Berry highway bridge is approximately 11 cables. It was estimated that the CATHERINE DESGAGNS travelled the 11 cables in about 12 minutes, giving an overall average speed of about 5.5 knots. The times which were recorded during the transit allow an estimate to be made of the speed at which the vessel covered various sectors of the total distance, as follows: When clearing the turning basin, the CATHERINE DESGAGNS briefly dropped the starboard anchor while manoeuvring to clear a barge and, when approaching the highway bridge, the main engine was turning full astern and an anchor was again dropped in an attempt to stop the vessel. These actions would result in a reduction in the apparent average speed in the relevant sectors. The river current at the time of the occurrence was negligible. 1.13 Evidence Regarding Vessel's Outbound Passage The master stated that he was concerned by the time it took to swing the vessel, but maintained that he did not consider the vessel to have been aground, as she was moving ahead and astern as he attempted to swing her. The master stated that the vessel's average speed during the passage was 5.3 knots. The chief officer stated that she was occupied with other tasks, but that at no time did she notice the vessel's speed being too high. The engineer who was on watch stated that full ahead was requested when the vessel left the turning basin and that this was maintained for four or five minutes until the orders were given for dead slow ahead, stop, and the double-ring full astern just before the impact. Two witnesses in a small boat stated that the CATHERINE DESGAGNS appeared to be gaining on their boat which would have been travelling at about 12 to 14 mph. They also stated that the vessel went wide on turns in the river. Witnesses from different locations ashore all agreed that the CATHERINE DESGAGNS was proceeding at a high speed. These witnesses included the operator of the railway bridge, who also stated that the span was still being raised and the signal light still red when the vessel passed through the bridge. In this respect, the chief officer stated that she thought that the bridge was fully raised when the vessel passed, but she did not observe the light, and the master was unsure as to whether the bridge was fully raised or the light was green at the time. The master stated that he was preoccupied with the navigation of the CATHERINE DESGAGNS and, because he was focused ahead, on where the vessel was going, other matters did not get his full attention. He considered the USCG call to the vessel to hold her position in the marina to be a matter for discussion and stated that it was mainly the wash from the propeller which damaged boats in the marina when the CATHERINE DESGAGNS went astern in preparation for passing through the highway bridge. The physical evidence was that a number of pleasure craft had been damaged by the vessel's propeller. 1.14 Railway Bridge Clearance The vertical clearance under the Norfolk and Western railway bridge is 10.67 m (35 feet) above chart datum when the span is down. On 06 August 1994, the water level was 0.71 m (2 feet 4 inches) above chart datum, reducing the clearance to 9.96 m in the closed position. When the stern of the CATHERINE DESGAGNS passed under the bridge, the centre-span height indicator showed that the span was 16.76 m (55 feet) above the closed level, giving a vertical clearance of 26.72 m (87.7 feet). The vessel's air draught was estimated to be about 24.38 m (80 feet) and the aftermast of the CATHERINE DESGAGNS would have cleared the bridge by about 2.34 m (7.7 feet). 1.15 Weather The weather was sunny and clear, with an air temperature of 22C. The vessel logged the wind as northerly at between 10 and 15 knots, but other witnesses stated that the wind was light and variable. 1.16 Tests for Substance Abuse The results of tests requested by the USCG and carried out on the master three days later in Montreal, Quebec, to detect drugs or alcohol were negative. 1.17 Situational Awareness and Information Processing Situational awareness has been defined as an accurate perception of the factors and conditions that affect a vessel and its crew during a specific period of time[5]. Persons in charge of the conduct of a vessel have to maintain situational awareness to navigate safely. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information such as location, speed, and the presence of hazards. When performing routine tasks, a person expects certain cues and will use these cues to quickly confirm the assessment of the situation and take what is apparently appropriate action without referring to other information which may conflict with the evaluation. A person tends to acquire information that confirms a hypothesis and ignore conflicting data. This tendency is called hypothesis locking or confirmation bias[6]. Frequently, it takes the intervention of another person with contradictory information to overcome such a bias. Once a hypothesis is adopted, it is very resistant to change; the phenomenon has also been described as reality construction[7]. When persons are stressed, there is a tendency for their attention to become even more narrowed so that even the cues which are present are missed, ignored, or discounted. Stress can also affect the perception of time. Under stressful conditions, people overestimate the amount of time that has passed. 1.18 Skill Degradation Different types of skills, once learned, are subject to degradation at different rates if not practised for periods of time. Continuous movement or psychomotor skills, such as steering, guiding, or tracking, are relatively impervious to decay. The skills needed to satisfactorily complete complex cognitive tasks requiring information processing, problem solving, recalling bodies of information, and communication between personnel, however, are subject to relatively rapid decay, within weeks if not practised.[8] Success at psychomotor tasks can lead persons to the conclusion that their skills have not decayed when, in fact, the more difficult and important cognitive skills are degraded.